Interpretation of Medical Findings in Suspected Child Sexual Abuse: An Update for 2018

Reviewing hereditary connective tissue disorders: Proposals of harmonic medicolegal assessments

Hereditary connective tissue disorders (HCTDs) are a heterogeneous group of inherited diseases. These disorders show genetic mutations with loss of function of primary components of connective tissue, such as collagen and elastic fibers. There are more than 200 conditions that involve hereditary connective tissue disorders, while the most known are Marfan syndrome, Osteogenesis Imperfecta, and Ehlers-Danlos syndromes. These disorders need continuous updates, multidisciplinary skills, and specific methodologic evaluations sharing many medicolegal issues. Marfan syndrome and Ehlers-Danlos syndromes show a high risk of early sudden death. As a consequence of this, postmortem genetic testing can identify novel genotype-phenotype correlations which help the clinicians to assess personalized cardiovascular screening programs among the ill subjects. Genetic testing is also essential to identify children suffering from Osteogenesis Imperfecta, especially when a physical abuse is clinically suspected. However, this is a well-known clinical problem even though there are still challenges to interpret genetic data and variants of unknown significance due to the current extensive use of new genetic/genomic techniques. Additionally, the more significant applications and complexities of genomic testing raise novel responsibilities on the clinicians, geneticists, and forensic practitioners as well, increasing potential liability and medical malpractice claims. This systematic review provides a detailed overview on how multidisciplinary skills belonging to clinicians, medicolegal consultants, radiologists, and geneticists can cooperate to manage HCTDs from autopsy or clinical findings to genetic testing. Thus, technical aspects need to be addressed to the medicolegal community since there is no consensus works or guidelines which specifically discuss these issues.

Incidence of child maltreatment diagnosis in electronic health records of a large integrated healthcare system: 2001-2018

The purpose of this study was to identify the number of children (<18years old) with an International Classification of Disease (ICD) diagnosis code for child maltreatment each year from 2001-2018 and examine differences by age, gender, and race/ethnicity. Data were drawn from the electronic health records of children (birth to <18years old) who were members of a large integrated healthcare system in California. We calculated the incidence rate (1 per 1000 children) for each year from 2001-2018 separately by age groups, gender, and race/ethnicity. Adolescents (11-15years old) had the overall highest incidence of all ages groups. Females had nearly twice the rate of males for the past 5years. Lastly, for race/ethnicity Black children had the highest incidence and Asian children the lowest. The findings demonstrate that maltreatment diagnosis in medical settings may be underused. Understanding the trends of these ICD codes by demographic characteristics yields information that health care providers may use to both increase the identification and documentation of child maltreatment.

Violence as a Health Problem

Violence is a public health problem, and when it affects childhood, it can cause illness throughout the individual's life. Apart from being able to cause damage in the physical, mental and social spheres, it represents a violation of the rights of the affected children, and a high consumption of resources, both economic and social. A multitude of investigations have improved attention to this violence. However, these advances are not consistent with the practical management of victims, both in Primary and Hospital Care. There is a significant area of improvement for paediatric care. Through this article, different professionals from all established paediatric health care facilities develop general lines of knowledge and action regarding violence against children. An overview is taken of the legislation related to childhood, the different types of abuse that exist, their effects, management and prevention. It concludes with an epilogue, through which we aim to move sensibilities. In summary, this work aims to promote the training and awareness of all professionals specialized in children's health, so that they pursue the goal of achieving their patients' greatest potential in life, and in this way, to help create a healthier society, with less disease, and more justice.

Child Sexual Abuse: Comparison of Male and Female Victims

ABSTRACT

In the scientific literature, few authors deal with child sexual abuse (CSA) in boys. In addition, these authors debate this phenomenon in most available articles without statistically evaluating the occurrence of different or similar distributions of variables under sex. In light of the above, the authors compared multiple variables between female and male samples. The aim was to explore the characteristics of boys' CSA, identifying the main differences existing compared with the same phenomenon occurring in girls. The authors selected 2 samples for sex: group A, females; group B, males. The authors statistically compared the main variables between the 2 groups. The study yielded the following main results: the population was characterized by 607 children (476 were females-group A; 131 were males-group B); the variables' source of the referral and the type of anogenital findings were statistically significant. These data gave new insights into the CSA phenomenon. Because this study pointed out that sexual abuse does not have the same characteristics in boys and girls, researchers and safeguarding agencies should consider the abovementioned differences when planning preventive strategies against CSA.

Distinct age-related differences among victims in cases of suspected child abuse

Evidence describing age-related differences among children with suspected physical and sexual child abuse is lacking. We describe findings in severe cases of suspected abuse. Cases with 756 children <15 years old were included during 2001-2013 at the Department of Forensic Medicine, Aarhus University, using forensic evaluation documents, medical records, and court proceedings. Eight percent of children <4 years old died from child abuse, 36% through violence resulting in death, and 64% by manslaughter, whereas 1% > 4 years old died, solely by manslaughter. External injuries were mainly located to head and torso in children <4 years old, changing to the upper and lower extremities in older children. Child sexual abuse was suspected in 52% of cases with living children <4 years old, 83% of children 4-7 years of age, 88% of children 8-11 years of age, and 93% of children >12 years old. Anogenital findings were mainly caused by other medical conditions in children <4 years old, hymenal clefts in the superior half of the hymenal rim were almost exclusively found in children between 8 and 11 years of age, whereas both superficial and complete hymenal clefts in the inferior half of the hymenal rim were found in children >12 years old. The present study describes age-related differences in victims of suspected child abuse. Fatal versus nonfatal child physical abuse and the significance of hymenal findings in child sexual abuse could be studied further.

Child Sexual Abuse: Forensic Medical Assessment of the Traumatic Injuries Over the Victim's Body

Child sexual abuse is a public health problem that affects children worldwide in all ethnic, educational, and socioeconomic groups. These assaults are extremely dangerous not only due to their direct physical traumas received at the time of the abuse, but they also have long-term consequences that can worsen the future quality of the victim's life. A retrospective study of all cases related to child sexual abuse for five years was performed by materials of the Clinic of Forensic Medicine and Deontology, Sofia, Bulgaria. Ninety-five cases involve children from both genders. The traumatic injuries were carefully examined and classified according to their localization over the victim's bodies and based on the time that had passed after the reported assaults. In cases of sexual violence, the most informative and pointing at the exact type of violence are the injuries situated in the anogenital area. Too often, there is a lack of physical findings, depending on the type of sexual violence or associated with the prolonged time that passes after the crime. Children are unaware of what they have to do after suffering such traumas, or they are scared to share their experience with different family members, which can lead to late forensic examination and lack of physical and biological findings, which are the most critical traces in the criminal prosecution of the crimes and this can be a possibility for the perpetrator not to be charged for his unlawful actions.

Knowledge of child abuse and neglect in nursing students: Assessment and perspectives

Misdiagnosis of child abuse and neglect can delay early treatment. Some authors have pointed out that nurses can miss child abuse and neglect diagnoses due to a lack of knowledge. It is unclear whether the lack of knowledge is due to students' insufficient preparation in nursing school and/or a deficiency in continuing education. An 18-item questionnaire was administered to final-year nursing students to assess their degree of knowledge on child abuse and neglect and to evaluate if the lack of knowledge was due to insufficient teaching/training during nursing school. The students were also asked to evaluate themselves by assigning a score to their knowledge. A statistical comparison was performed to define whether sufficient/insufficient results were associated with the following variables: sex, pediatric or general nursing student, attending pediatric lectures, training in pediatric wards/ambulatories, and attending specific lectures on child abuse and neglect. The study population comprised 175 students (154 females, 20 males, 1 unknown). Exactly 66.3% of the participants had ≤9/18 correct answers. Of all students, 77.7% self-evaluated their level of knowledge as ≤5/10. The comparisons yielded statistically significant differences between the groups with sufficient objective knowledge and those unrelated to training in pediatric wards/ambulatories or pediatric nursing students. Overall, there was little objective knowledge on the subject, which may be related to insufficient teaching/training in nursing schools. Useful corrective strategies include further teaching on child abuse and neglect, preferably using a practical approach. Further, common teaching/training programs should be conducted by both pediatric and general nursing schools.

Interpretation of medical findings in suspected child sexual abuse: An update for 2023

Health care professionals who examine children who may have been sexually abused need to be able to recognize, and photo-document any physical signs, and to have access to expert reviewers, particularly when signs concerning for sexual abuse are found. Although the general consensus among practitioners is that children will show few signs of sexual abuse on examination, there is considerable variability and rates of positive exam findings among practitioners of different professions, practice settings, and countries. This review will summarize new data and recommendations regarding the interpretation of medical findings and sexually transmitted infections (STIs); assessment and management of pediatric patients presenting with suspected sexual abuse or assault; and testing and treating patients for STIs. Updates to a table listing an approach to the interpretation of medical findings are presented, and reasons for changes are discussed.

Artificial Intelligence and Child Abuse and Neglect: A Systematic Review

All societies should carefully address the child abuse and neglect phenomenon due to its acute and chronic sequelae. Even if artificial intelligence (AI) implementation in this field could be helpful, the state of the art of this implementation is not known. No studies have comprehensively reviewed the types of AI models that have been developed/validated. Furthermore, no indications about the risk of bias in these studies are available. For these reasons, the authors conducted a systematic review of the PubMed database to answer the following questions: "what is the state of the art about the development and/or validation of AI predictive models useful to contrast child abuse and neglect phenomenon?"; "which is the risk of bias of the included articles?". The inclusion criteria were: articles written in English and dated from January 1985 to 31 March 2023; publications that used a medical and/or protective service dataset to develop and/or validate AI prediction models. The reviewers screened 413 articles. Among them, seven papers were included. Their analysis showed that: the types of input data were heterogeneous; artificial neural networks, convolutional neural networks, and natural language processing were used; the datasets had a median size of 2600 cases; the risk of bias was high for all studies. The results of the review pointed out that the implementation of AI in the child abuse and neglect field lagged compared to other medical fields. Furthermore, the evaluation of the risk of bias suggested that future studies should provide an appropriate choice of sample size, validation, and management of overfitting, optimism, and missing data.

Clinical Review: Prepubertal Bleeding

BACKGROUND

Prepubertal bleeding is a common presentation in the pediatric office and can be distressing for patients and families. A comprehensive approach to diagnosis and management allows clinicians to identify patients at risk for worrisome pathology and arrange timely care.

OBJECTIVE

We aimed to review the key features of clinical history, physical exam, and diagnostic workup of a child presenting with prepubertal bleeding. We reviewed potential pathologies requiring urgent investigations and management, such as precocious puberty and malignancy, as well as more common etiologies, including foreign bodies and vulvovaginitis.

CONCLUSION

Clinicians should approach each patient with the goal of excluding diagnoses that require urgent interventions. A thoughtful clinical history and physical exam can inform appropriate investigations to optimize patient care.

Medico-legal study of the hymen

BACKGROUND

The study of hymen morphology and injuries is critical in forensic medicine, particularly in Iraq and other Asian countries. Problems with the hymen can have serious social consequences.

AIM OF THE STUDY

The aim of this study is to shed light on various hymen's variants, as well as the possible causes of their injuries and their medicolegal significance.

METHOD

This study was carried out at Baghdad's medico-legal directorate (M.L.D.) from January 1st to March 31st, 2017. There were 127 cases in total. They ranged in age from two to sixty. The morphology of the hymens, their injuries, and other relevant details were documented using a specific questionnaire.

RESULTS

Compared to other varied examinations undertaken, such as infertility, impotence, and others, the examination of the hymen made up (5.1%) of all examinations conducted in the Medico-Legal Directorate (M.L.D.) clinic in Baghdad. The majority of the women tested were over the age of 14. The annular hymen was the most common variant (57.3%). The elastic hymens percentage was 14.6% while the Imperforated variant had the lowest prevalence (0.8%). The majority of the properties of the examined hymens were smooth free edge, medium consistency, and medium sized hymen opening. The majority of the cases involved female children (prepubertal girls) who were accidently injured, followed by sexual assaults and wedding night doubts. The majority of hymen tears (40.2%) were old. Multiple tears (47.5%) outnumbered single tears (37.3%). Fresh tears were only observed in adult girls.

CONCLUSION

The annular variant of the smooth free edge, average consistency, and average hole size is the most common hymens. The elastic hymens were a main reason for the referral of cases for medical examination due to wedding night doubts. In more than half of the cases, the hymens were smooth with no transection or deep notches.

Anogenital HSV in Children: Should Providers Be Concerned for Sexual Abuse?

OBJECTIVE

Anogenital herpes simplex virus (HSV) is most commonly acquired via sexual transmission, although other nonsexual modes of transmission have been proposed. When a child presents with a first-time outbreak of anogenital HSV, providers must consider sexual abuse. There are currently no evidence-based consensus guidelines to inform management of these patients. The purpose of this study was to describe how child abuse pediatricians (CAPs) evaluate children with anogenital HSV infection and determine whether any consistent practice patterns are followed.

PARTICIPANTS AND SETTING

The patients included in this study were children between the ages of 0 and 12 years with a first-time outbreak of anogenital HSV who were medically evaluated by a CAP.

METHODS

Patient charts were retroactively reviewed for the period of January 1 2004 to May 1 2020.

RESULTS

Twenty-two cases were referred for evaluation by a CAP in the chosen time frame. Fifteen were seen in person. Ten of these patients were interviewed, 15 had an anogenital exam with colposcopy, and 14 were tested for at least one other sexually transmitted infection. A diagnosis of sexual abuse was made for 1 patient.

CONCLUSION

This study demonstrates that although nonsexual transmission of anogenital HSV may be possible, providers must still consider sexual abuse. Children with a first-time outbreak of anogenital HSV should have a comprehensive evaluation for sexual abuse, including interview, physical exam, and testing for sexually transmitted infections. Evidence-based concerns for sexual abuse should be reported to child protective services.

Nonoffending Caregiver Support After Child Sexual Abuse: Essentials for the Forensic Nurse

Child sexual abuse (CSA) is a pediatric health problem of epidemic proportions. CSA can result in significant lifelong physical and mental health consequences. A disclosure of CSA affects not only the child but also everyone close to the child. Nonoffending caregiver support after a disclosure of CSA is key to optimal victim functioning. Forensic nurses play an integral role in the care of CSA victims and are uniquely positioned to ensure best outcomes for both child victims and their nonoffending caregivers. In this article the concept of nonoffending caregiver support is explored, and = implications for forensic nursing practice delineated.

Experience of obstetricians and gynecologists in the management of medicolegal cases in Egypt

BACKGROUND

Obstetrics and gynecology (OB/GYN) is concerned with both fetal and maternal wellbeing with doubled professional responsibilities. Also, OB/GYN specialists are engaged in management of medicolegal cases (MLC). This study had an in-depth look at handling of MLC by obstetricians and gynecologists in Egypt. Also, influence of religious and cultural norms on OB/GYN practice was investigated.

METHODS

A questionnaire was formulated in compliance with literature and modulated according to religious and cultural background.

RESULTS

Responses were received from practitioners in 19 governorates. 28% of respondents were accused of malpractice. 87.3% of participants denoted increasing rate of litigations over last years. The commonest mentioned error is intra-operative problems (60%), whereas the commonest harm is neonatal deaths (46.7%). The mean participants' awareness score regarding elements of malpractice was 1.49 ± 0.76 (maximum possible score is 4). 18.7% of respondents managed cases of sexual assaults and premarital sexual relations. Hymen repair is not justified by 53.3% of participants. Termination of pregnancy before 16 weeks without medical indication is unaccepted by 96.7% of participants. The mean participants' awareness score regarding precautions of therapeutic abortion was 3.34 ± 1.63 (maximum possible score is 5).

CONCLUSIONS

OB/GYN specialists are at high risk of accusation with inadequate measures to guard against malpractice claims in Egypt. High controversy among respondents regarding management of cases with premarital sexual acts and termination of pregnancy was elucidated.

Virginity Testing

Virginity testing is a human rights violation involving an examination of the female genitalia, often by a healthcare professional, intended to correlate the appearance of the hymen in women or girls with previous sexual intercourse. Virginity testing examinations are conducted under a variety of circumstances and settings: before marriage to establish virginity, to disprove or prove an allegation of sexual violence, to legally assess the allegation of a woman or girl not being a virgin in the absence of bleeding on her wedding night, and to intimidate political activists and detainees. Despite the United Nations Human Rights Office, United Nations Women, and World Health Organization calling for a ban on this practice, it remains common practice in various regions around the world. It is the position of the International Association of Forensic Nurses that virginity testing cannot accurately determine if consensual sexual activity or sexual abuse has occurred and can result in significant physical, psychological, and social consequences.

How can school help victims of violence? Evaluation of online training for European schools’ staff from a multidisciplinary approach

The interventions used to prevent or treat violence against children, particularly sexual abuse, tend to only consider the target audience as their main source of data. We tested the effect of an online training for school staff members in Europe through three studies. In Study I, we interviewed 5 adult women (Mage = 49.2, SD = 5.81) who were victims of sexual abuse during childhood to assess what school could have done during that time to protect them. Through Study II, we collected data on 66 school staff members to assess feasibility (based on quantitative indicators) and to explore the changes they would make to their everyday practice due to the training course (using qualitative analysis). In Study III, we used network analysis to assess to what extent the actions described by school staff in Study II met the needs expressed by the victims in Study I. Findings of Study I revealed new proposals from the victims’ perspective, such as working with the perpetrators. Study II showed the feasibility of training and identified five types of action that school staff members will include in their everyday working dynamics due to the training: detection (e.g., Greater attention to relationships with peers), reporting (e.g., Now I know that suspecting a case of child abuse is enough to report), everyday practices (e.g., Introducing a calming space), changes at school level (e.g., Propose the training course to the school management team) or practices that could belong to more than one category (e.g., Greater awareness of the activities undertaken by the school). Study III provided evidence that some of these changes (e.g., reporting without looking for proof) were in line with some of the victims’ expectations (e.g., listen to the children). We also identified gaps that need to be further developed.

Polyembolokoilamania in Child Sexual Abuse: Physical Examination Findings After Abusive Foreign Body Insertion and Literature Summary

OBJECTIVE

To characterize the physical examination findings in children and adolescents who disclosed insertion of an object into their bodies as part of their sexual abuse history and to identify how this population compares to similar cases described in the published literature.

METHODS

This is a 15-year retrospective review of children younger than 18 years seen at a large urban children's assessment center. In addition, we reviewed and summarized the last two decades of literature characterizing pediatric anogenital foreign bodies to better understand previously described findings in similar populations.

RESULTS

Sixty-eight children whose abuse histories included anal or genital insertion of a foreign body still presented with normal examination findings in the vast majority (89.7%) of cases, despite the diversity of items described. The literature on anogenital foreign bodies was sparse, offered a variety of approaches to the overall evaluation of such cases, and demonstrated inconsistent consideration of child sexual abuse in response to the diagnosis.

CONCLUSIONS

This article further supports the literature reflecting the overall rarity of abnormal anogenital findings in the clinical assessment for sexual abuse.

Multidisciplinary Approach to Emergent Sexual Abuse in a Pediatric Emergency Department: A Simulated Child Advocacy Center Model of Care

INTRODUCTION

The purpose of this study was to compare child sexual abuse interview disclosures and judicial outcomes for cases of child and adolescent sexual abuse/assault seen in a pediatric emergency department (PED) before and after the implementation of a simulated child advocacy center (CAC) multidisciplinary model of care.

METHOD

A retrospective chart and legal records review was conducted from both the PED model of care group and the simulated CAC multidisciplinary model of care for judicial outcomes, child sexual abuse interview disclosures, and sexual abuse case characteristics.

RESULTS

The simulated CAC multidisciplinary model of care did not result in increased indictments, pleas, trials, or disclosure of sexual abuse in the sexual abuse interview when compared with the PED model of care. The simulated CAC multidisciplinary model of care did result in a significantly higher rate of sexual abuse interview completion.

DISCUSSION

Demographic risk factors for sexual abuse victimization as well as perpetration have been identified in the literature and were supported by this study. Law enforcement and child protective services were more frequently present in the PED under the simulated CAC multidisciplinary model allowing for improved protection of children.

Child sexual abuse detection in the pediatric emergency room

BACKGROUND

Children who report sexual abuse are often first evaluated in a Pediatric Emergency Room (ER).

OBJECTIVE

This study aims to describe clinical characteristics and management among these children.

PARTICIPANTS AND METHODS

A retrospective review of child sexual abuse (CSA) cases in the ER of a tertiary hospital in Madrid over a 9-year period (January 2011 to April 2020) was conducted. 213 children up to 16 years old were included. Descriptive statistics were performed.

RESULTS

An 83% of victims were girls, of whom 97.7% reported physical contact. The mean age was 8.5 ± 4.4 years, with two peaks of incidence at ages of 3 and 13. Aggressors were known by the victim in 77.8% of cases. Anogenital lesions were present in 39.9% of children who described physical contact, of which 31.7% were suspicious or specific of CSA. We obtained positive microbiological samples in 41 patients, with 14.6% specific findings for sexually transmitted infections (STIs). 23,9% received prophylaxis for bacterial STIs and 13.6% against HIV. 59.6% were followed-up in outpatient clinics. Since our protocol renovation in 2019, we observe a statistically significant increase in microbiological detection (p < .005) and outpatient follow-up (p < .001).

CONCLUSIONS

STIs screening should always be done when physical contact is reported for eventual treatment and perpetrator prosecution, as physical lesions are frequently not found. The optimal treatment of CSA requires the use of renewed specific protocols and the involvement of multidisciplinary trained teams to ensure adequate medical and personal care.

Statement of the DGGG - Recommendations on the Care and Support of Female Minors Suspected of Having Been Subjected to Acute Sexual Violence or Rape

Ziele Die vorgelegten Empfehlungen sollen zur weiteren Verbesserung und Standardisierung der ärztlichen Versorgung von Betroffenen sexualisierter Gewalt, insbes. von einer Vergewaltigung betroffenen weiblichen Minderjährigen in Deutschland beitragen. Sie wendet sich vor allem an Frauenärztinnen und Frauenärzte in der Klinik und in der Niederlassung und ergänzt die umfangreiche Kinderschutzleitlinie der Bundesrepublik Deutschland. Methoden Unter Einbeziehung der Ergebnisse einer umfassenden selektiven Literaturrecherche wurden von einer interdisziplinär besetzten Gruppe von Expertinnen und Experten in einem 3-stufigen Verfahren im Auftrag des Vorstands der DGGG diese Empfehlungen erarbeitet und im Konsens verabschiedet. Zusammenfassung Diese DGGG-Stellungnahme ist entsprechend dem Alter der Betroffenen (ca. 14 bis 17 Jahre/pubertär; 0 bis ca. 13 Jahre/präpubertär) zweigeteilt. Dies hat medizinische, strukturelle und forensische Gründe. Es werden zahlreiche Empfehlungen zum Umgang mit den mutmaßlich von akuter sexualisierter Gewalt bzw. einer Vergewaltigung betroffenen Minderjährigen, zur Erstversorgung, zu Versorgungsformen (z. B. Vertrauliche Spurensicherung), zur Anamneseerhebung, zur medizinisch-forensischen Untersuchung, zur medizinischen, psychischen und psychosozialen Versorgung sowie zur Nachbetreuung gegeben.

Child abuse and neglect: Are future medical doctors prepared?

Diagnosis of child abuse and neglect is a challenging matter: in case of misdiagnosis, the child cannot benefit from an early treatment; erroneous interpretation may generate legal issues. Some studies reported physicians' lack of knowledge in child abuse and neglect. However, it is not clear if the reasons of this lack relay on an insufficient preparation of students during medical school and/or a deficiency in continuing medical education during/after fellowships. For these reasons, the authors of the present manuscript administered a questionnaire to last year medical students to: evaluate the degree of knowledge on this thematic in a medical student sample; understand if the abovementioned lack may be due to insufficient preparation of students during medical school. Study population included 179 students. The 77.7% demonstrated a low knowledge of this thematic, but they showed a high insight of their lack. The authors pointed out that medical school education can represent a weak point in future medical doctor knowledge on child abuse and neglect. It also allowed to identify as study sample's medical students had high awareness of their lacks in this field. In addition, comparison of medical schools from different geographical areas suggested common issues independent of which accreditation system is implemented. Thus - independent of which corrective strategy will be planned - the study highlighted necessity for each medical school to define: its current ability to properly train students in child abuse and neglect; students' awareness of their level of expertise. This can help schools to identify the most suitable correctives.

Pediatric Emergency Department Testing for Gonorrhea and Chlamydia in Children

OBJECTIVE

This study aimed to describe trends in the utilization of nucleic acid amplification (NAAT) testing for gonorrhea and chlamydia in US pediatric emergency departments. Nucleic acid amplification has been recommended over genital culture by the American Academy of Pediatrics and Centers for Disease Control and Prevention for children evaluated for sexual abuse.

METHODS

We conducted a multicenter study of children aged 12 months to 11 years tested for gonorrhea and chlamydia between 2004 and 2018 at 22 hospitals in the Pediatric Health Information System. We included patients diagnosed with maltreatment concerns and/or genitourinary (GU) symptoms. The primary outcome was prevalence of testing with NAAT, culture, or both. We analyzed groups based on patient sex, as well as diagnoses of maltreatment versus GU symptoms.

RESULTS

A total of 36,312 visits were analyzed. Visits were 73.4% girls and 26.6% boys. During the study period, there was an increase in use of NAAT-only testing for girls (49.3% to 94.3%; P < 0.001) and boys (54.5% to 96.1%; P < 0.001). There was a decrease in use of culture alone for girls (40% to 1.6%; P < 0.001) and boys (38.7% to 0.8%; P < 0.001). Use of both tests in the same encounter was higher among children diagnosed with maltreatment than GU symptoms, regardless of sex (P < 0.001).

CONCLUSIONS

Over a 14-year period, downtrend of culture use with increase in NAAT was observed, suggesting general adherence to evidence-based guidelines. Almost 10% of children diagnosed with maltreatment continued to be tested with culture. This could indicate provider concerns regarding test accuracy, legal admissibility, or lack of test availability.

Synthesizing a Talking Child Avatar to Train Interviewers Working with Maltreated Children

When responding to allegations of child sexual, physical, and psychological abuse, Child Protection Service (CPS) workers and police personnel need to elicit detailed and accurate accounts of the abuse to assist in decision-making and prosecution. Current research emphasizes the importance of the interviewer’s ability to follow empirically based guidelines. In doing so, it is essential to implement economical and scientific training courses for interviewers. Due to recent advances in artificial intelligence, we propose to generate a realistic and interactive child avatar, aiming to mimic a child. Our ongoing research involves the integration and interaction of different components with each other, including how to handle the language, auditory, emotional, and visual components of the avatar. This paper presents three subjective studies that investigate and compare various state-of-the-art methods for implementing multiple aspects of the child avatar. The first user study evaluates the whole system and shows that the system is well received by the expert and highlights the importance of its realism. The second user study investigates the emotional component and how it can be integrated with video and audio, and the third user study investigates realism in the auditory and visual components of the avatar created by different methods. The insights and feedback from these studies have contributed to the refined and improved architecture of the child avatar system which we present here.

Hymen and virginity: What every paediatrician should know

Paediatricians may face the notion of 'virginity' in various situations while caring for children and adolescents, but are often poorly prepared to address this sensitive topic. Virginity is a social construct. Despite medical evidence that there is no scientifically reliable way to determine virginity, misconceptions about the hymen and its supposed association with sexual history persist and lead to unethical practices like virginity testing, certificate of virginity or hymenoplasty, which can be detrimental to the health and well-being of females of all ages. The paediatrician has a crucial role in providing evidence-based information and promoting positive sexual education to children, adolescents and parents. Improving knowledge can help counter misconceptions and reduce harms to girls and women.

Sexual violence: 10 years of case studies in a hospital in Northern Italy

Background: In the past twenty years, the fight against sexual violence has become a common goal of the entire European Union, due to a greater socio-cultural awareness of the population and the need to create guidelines for common action. Italian Law no. 66 of February 15, 1996, regarding the “Rules against sexual violence” which, with the appropriate amendments, is still in force today, defines 3 types of sexual offenses through the articles 609 of the Penal Code.

Design and Methods: This study analyzes the cases relating to one of the hospitals in Northern Italy, during the decade January 2010 - December 2019, relating to suspected/reported cases of sexual violence, group sexual violence and sexual acts with minors. This study was carried out by acquiring information relating to subjects who had been victims of a sexual crime through the analysis of the consultations drawn up by specialist medical staff in the submentioned hospital. These consultations are defined by specific medical protocols that must be activated every time a victim of a suspected sexual offense comes into the Emergency Room (ER). The data were processed with descriptive analyzes, the qualitative variables were synthesized with absolute and percentage frequencies, while the quantitative variables with mean and interpolation of the data, to identify a trend line. In order to hypothesize the possible future trend of the phenomenon, data were collected relating to the type of crime according to the Penal Code, gender and age of the victim. This article also outlines future directions for improving research.

Results: Our data shows that females, of any age, are the most affected in all sexual crimes, often share home with their aggressor, usually a man, and in most cases, they come to the medical observation without any lesion on their body.

Conclusions: In order to provide a global vision of the situation and of the diffusion throughout the territory, studies like this one could be carried out in various Italian provinces. Besides, we hope that the high degree of commitment on the part of society and institutions in combating sexual violence, through information campaigns and incitements to report, will lead in a few years to a reduction in the number of victims of repeated violence (especially in family contexts) and, consequently, also in the total number of acts of violence that comes to the attention of the healthcare facilities. Finally, primary prevention of sexual violence must begin early because a substantial portion is experienced at a young age. It will be necessary to prevent these forms of violence with strategies that address known risk factors for perpetration (e.g., low family support, high poverty, low parental education, absent or single parenting, parental substance abuse, domestic violence, low caregiver warmth), by changing social norms and behaviors and by identifying protective factors that could be strengthened.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Child Maltreatment and Neglect

Emergency medicine clinicians are mandated reporters, legally, which obligates clinicians to report any behavior suspicious for child maltreatment to local authorities. Pediatric patients often present to the emergency department with concern for physical injury and other pervasive complaints. In some cases, these injuries are nonaccidental. To appropriately advocate and protect children from further physical and emotional trauma, it is important for clinicians to recognize the signs and symptoms of child maltreatment and sexual abuse.

Rare (uro-)genital pathologies in young girls mimicking sexual abuse

Examinations of young children for suspicions of sexual abuse are challenging for the involved medical specialists because the consequences of the interpretation of the findings can be severe and dramatic. A broad knowledge of differential diagnoses including rare pathologies like urethral prolapse and failure of the midline fusion of the perineum, known as perineal groove, is essential in order to avoid unnecessary diagnostics and treatment, prejudgment, and to reduce patient family’s anxiety. We report two independent cases of girls aged 7 months and 5 years suffering from these rare pathologies, one presenting with painless lower genital tract bleeding, the other showing a lesion of the perineum as random finding during a neuropediatrician’s consultation. In both cases, the pathologies were initially misdiagnosed as injuries due to sexual assault, and judicial investigation procedures were initiated. In this paper, the characteristic symptoms and morphology of urethral prolapse and perineal groove are presented to enhance the awareness of these pathologies among forensic experts and help to establish the correct diagnosis.

Brazilian Protocol for Sexually Transmitted Infections 2020: sexual violence

This article addresses sexual violence, as part of the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health. Guidance is provided in programmatic and operational management, focusing on the service network for people in situation of sexual violence, recommendations to health staff about pregnancy and viral and non-viral sexually transmitted infections prophylactic measures, in addition to surveillance action strategies. Sexual violence is an encompassing issue that includes wider areas than the health field. It involves conceptual and programmatic challenges for health staff, at the forefront of care for affected people and also to the implementation of prevention strategies addressed to the whole society. Sexual violence is one of the principal forms of human rights violation, affecting the right to life, health, and bodily integrity.

Hymenal transections in children found by photocolposcopy in suspected sexual abuse cases is associated with a history of bleeding

OBJECTIVE

To investigate the difference in selected variables between children with and without hymenal transection, which is a healed defect that extends through the entire depth of the posterior hymenal membrane to the vaginal wall.

MATERIALS AND METHODS

All female children from Southern Denmark who were examined by photocolposcopy in a six-year period were included in a retrospective cohort study. Statistical analyses included a chi-square test and a logistic regression analysis.

RESULTS

Eighty girls under 15 years of age who were suspected to have been sexually abused were included. Sixteen of the girls had hymenal transections. There was a statistically significant correlation between the presence of hymenal transections and reported fresh bleeding after the assault.

CONCLUSION

Bleeding after an assault could indicate more severe lesions, which might explain why these patients did not heal completely.

Prepubescent Female Genital Examination Images: Evidence-Informed Learning Opportunities

OBJECTIVES

To determine diagnoses and image features that are associated with difficult prepubescent female genital image interpretations.

DESIGN AND SETTING

This was a mixed-methods study conducted at a tertiary care pediatric center using images from a previously developed education platform.

PARTICIPANTS

Participants comprised 107 medical students, residents, fellows, and attendings who interpreted 158 cases to derive case difficulty estimates.

INTERVENTIONS

This was a planned secondary analysis of participant performance data obtained from a prospective multi-center cross-sectional study. An expert panel also performed a descriptive review of images with the highest frequency of diagnostic error.

MAIN OUTCOME MEASURES

We derived the proportion of participants who interpreted an image correctly, and features that were common in images with the most frequent diagnostic errors.

RESULTS

We obtained 16,906 image interpretations. The mean proportion correct scores for each diagnosis were as follows: normal/normal variants 0.84 (95% confidence interval [CI] 0.82, 0.87); infectious/dermatology pathology 0.59 (95% CI 0.45, 0.73); anatomic pathology 0.61 (95% CI 0.41, 0.81); and, traumatic pathology 0.64 (95% CI 0.49, 0.79). The mean proportion correct scores varied by diagnosis (P < .001). The descriptive review demonstrated that poor image quality, infant genitalia, normal variant anatomy, external material (eg, diaper cream) in the genital area, and nonspecific erythema were common features in images with lower accuracy scores.

CONCLUSIONS

A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. These data can be used to inform the design of teaching interventions to improve skill in this area.

[Brazilian Protocol for Sexually Transmitted Infections 2020: sexual violence]

This article addresses sexual violence, a topic that makes up the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Ministry of Health of Brazil. Guidance is given to managers in programmatic and operational management with a focus on the service network for people in situations of sexual violence, recommendations to health professionals about prophylactic measures of pregnancy and viral and non-viral sexually transmitted infections, in addition to strategies for surveillance actions. Sexual violence is a broad problem that goes beyond the health field and involves conceptual and programmatic challenges for both health professionals, who are at the forefront of care for affected people, and for society, in terms of possible forms of prevention.

Medical approach to children who may have been sexually abused-a narrative review

The medical approach to children who may have been sexually abused involves several issues and aspects that need to be considered. The medical examination of children with suspected sexual abuse is important, but a detailed medical history from the child and the parents or caretakers is always part of every thorough examination. It can take a long time until victims disclose their abuse and physical signs of abuse may no longer be visible at the time of examination. If the physical examination is performed non-acutely, only 2.2% of sexually abused girls show diagnostic signs of injury. An experienced examiner should ideally perform the examination in suspected sexual abuse of children. Knowledge of the current literature is of importance, as the interpretation of findings has changed over the past decades and it can be difficult to differentiate between normal variants, symptoms of other medical problems, and signs of sexual assault. Furthermore, sexual abuse of children presents in various form, not necessarily leading to physical injuries. Since 1992, Adams et al. publish a regularly updated system for the classification of anogenital findings in children with suspected sexual abuse, including a detailed list of physical findings and infections related to sexual abuse. The purpose of this article is to summarize important aspects of the medical approach to children with suspected sexual abuse according to the current literature.

What to do when a child reports sexual harassment and sexual assault to a medical professional

Global exposure of children to sexual abuse is widespread. Disclosure may be extremely upsetting for both families and medical professionals. This review provides medical practitioners with practical tips for a stepwise approach of the child who discloses sexual abuse. Having secured a private examination room, the physician should approach the child and caregivers separately to determine the level of concern for abuse and the urgency of the situation. The medical evaluation is based on the information gathered, including a complete physical examination, inspection of the genitalia, collection of forensic evidence, and testing for sexually transmitted diseases. On a case-by-case basis, the need for surgical intervention, prophylactic treatment, and immunization is discussed. Finally, important questions for the medical team to address are outlined with the goal of supporting the child and his/her family and ultimately stopping the abuse.

Sexual Abuse in Children: What the General Practice Ob/Gyn Needs to Know

The medical evaluation of a child who may have been sexually abused can be a challenge for physicians who are unfamiliar with the wide variation in normal genital anatomy in prepubertal girls. Signs of injury are rarely found, unless the child is examined within 72 hours of the event. This article will provide some history about how guidelines for medical care of these children have been developed, and list some of the findings that are normal or normal variants, caused by other conditions, or due to trauma or infection.

The medical evaluation of prepubertal children with suspected sexual abuse

Child sexual abuse is an important and not uncommon problem. Children who have been sexually abused may present to a physician's office, urgent care centre, or emergency department for medical evaluation. A medical evaluation can provide reassurance to both child and caregiver, identify care needs, and offer an accurate interpretation of findings to the justice and child welfare systems involved. Given the potential medico-legal implications of these assessments, the performance of a comprehensive evaluation requires both current knowledge and clinical proficiency. This position statement presents an evidence-based, trauma-informed approach to the medical evaluation of prepubertal children with suspected or confirmed sexual abuse.

L’évaluation médicale des enfants prépubères qu’on soupçonne d’être victimes d’une agression sexuelle

L’agression sexuelle sur les mineurs est un problème important et relativement courant. Les enfants victimes d’une agression sexuelle peuvent se présenter au cabinet d’un médecin, à un centre de soins d’urgence ou au département d’urgence d’un hôpital en vue d’une évaluation médicale. Cette évaluation peut rassurer à la fois l’enfant et la personne qui l’a à sa charge, établir les soins à apporter et offrir une interprétation précise des constatations au système de justice et aux services de protection de l’enfance. Étant donné le potentiel de conséquences médicolégales, une évaluation approfondie exige à la fois des connaissances à jour et des compétences cliniques. Le présent document de principes propose une approche fondée sur des données probantes et respectueuse des traumatismes lors de l’évaluation médicale des enfants prépubères victimes d’une agression sexuelle présumée ou confirmée.

Deliberate practice as an educational method for learning to interpret the prepubescent female genital examination

BACKGROUND

Correct interpretation of the prepubescent female genital examination is a critical skill; however, physician skill in this area is limited.

OBJECTIVE

To complement the bedside learning of this examination, we developed a learning platform for the visual diagnosis of the prepubescent female genital examination and examined the amount and rate of skill acquisition.

PARTICIPANTS AND SETTING

Medical students, residents, and fellows and attendings participated in an on-line learning platform.

METHODS

This was a multicenter prospective cross-sectional study. Study participants deliberately practiced 158 prepubescent female genital examination cases hosted on a computer-based learning and assessment platform. Participants assigned the case normal or abnormal; if abnormal, they identified the location of the abnormality and the specific diagnosis. Participants received feedback after every case.

RESULTS

We enrolled 107 participants (26 students, 31 residents, 24 fellows and 26 attendings). Accuracy (95 % CI) increased by 10.3 % (7.8, 12.8), Cohen's d-effect size of 1.17 (1.14, 1.19). The change in specificity was +16.8 (14.1, 19.5) and sensitivity +2.4 (-0.9, 5.6). It took a mean (SD) 46.3 (32.2) minutes to complete cases. There was no difference between learner types with respect to initial (p = 0.2) or final accuracy (p = 0.4) scores.

CONCLUSIONS

This study's learning intervention led to effective and feasible skill improvement. However, while participants improved significantly with normal cases, which has relevance in reducing unnecessary referrals to child protection teams, learning gains were not as evident in abnormal cases. All levels of learners demonstrated a similar performance, emphasizing the need for this education even among experienced clinicians.

Using Telehealth for Pediatric, Adolescent, and Adult Sexual Assault Forensic Medical Examinations: An Integrative Review

OBJECTIVE

Improved access to qualified nurse examiners to perform sexual assault forensic examinations is needed. This integrative review examines the current research literature on synchronous "real-time or live" telehealth support and guidance during pediatric, adolescent, and adult sexual abuse/assault forensic examinations.

METHODS

Informational databases (CINAHL, Health Source: Nursing/Academic Edition, Medline, PsychInfo, and Violence & Abuse Abstracts) were searched, and research articles including live telehealth for sexual assault survivors were reviewed (n = 98).

RESULTS

Review of the articles resulted in the inclusion of seven studies that utilized live video telehealth during the sexual assault forensic examination.

CONCLUSION

The current research literature supports the premise that synchronous telehealth is a promising modality for this patient population. However, the lack of large comprehensive studies warrants additional research to understand outcomes and develop best practices. Additional research studies are needed to evaluate the effectiveness, cost, and criminal justice impact of this intervention.

A Novel Scale to Communicate Perceived Likelihood of Child Sexual Abuse

BACKGROUND AND OBJECTIVE

Child abuse pediatricians (CAPs) are often asked to determine the likelihood that a particular child has been sexually abused. These determinations affect medical and legal interventions, and are important for multisite research. No widely accepted scale is available to communicate perceived sexual abuse likelihood. In this study, we measure intra- and inter-rater reliability of a 5-point scale to communicate child sexual abuse likelihood.

METHODS

We developed a 5-point scale of perceived likelihood of child sexual abuse with example cases and medical-legal language for each risk category. We then surveyed CAPs who regularly perform sexual abuse evaluations using the abstracted facts of 15 actual cases with concern for sexual abuse. A subset of participants rated the same vignettes again, 1 month later.

RESULTS

Of 512 invited participants, 240 (46.7%) responded, with 145 (28.3%) indicating that they regularly perform sexual abuse evaluations, 116 initially completing all 15 vignettes, and 36 completing repeat ratings at least 1 month later. The scale showed consistent stepwise increase in mean perceived likelihood of abuse and intention to report for each increase in scale rating. Inter-rater agreement was substantial (Fleiss' weighted kappa 0.64) and test-retest reliability among 36 participants was almost perfect (Cohen's kappa = 0.81).

CONCLUSIONS

We introduce a scale of perceived sexual abuse likelihood that appears to reflect CAPs' perceptions and intention to report. This scale may be a reasonable metric for use in multicenter studies. CAPs demonstrated substantial inter- and intrarater reliability when evaluating sexual abuse likelihood in case vignettes. While this scale may improve communication of sexual abuse likelihood among experts, its examples should not be used as a legal standard or a clinical criterion for sexual abuse diagnosis.

Forensic medical evaluation of children who present with suspected sexual abuse: How do we know what we know?

The past 40 years have seen significant changes in the way children's genital findings are interpreted in the context of suspected sexual abuse. Many findings previously thought to be diagnostic of sexual abuse are now recognised to be normal variants, caused by other medical conditions or have insufficient specificity to make a definite diagnosis of abuse. Use of the Adams classification in recent years has provided a common language and practical framework for describing and categorising genital findings in children. This review article addresses our current understanding of how to interpret genital findings in children, the evidence on which this interpretation is based, gaps that remain in our knowledge and suggestions for future research.

Knowledge, Attitude and Practice of Child Sexual Abuse Prevention among Parents of Children with Hearing Loss: A Pilot Study in Beijing and Hebei Province, China

This study aimed to examine the knowledge, attitude, and practice (KAP) of child sexual abuse (CSA) prevention among parents of children with hearing loss. The study involved 127 pairs of parents with deaf and hard of hearing children from three special education schools in Beijing and Hebei province, China. The findings revealed that the parents lacked knowledge about CSA prevention, such as the character of perpetrators and child victims. Parents were supportive about potential CSA prevention education in schools. Most parents told children much about personal safety, but topics on CSA prevention were still insufficient. The study also found that education level was significantly associated with knowledge and attitude. Elder parents knew more and talked more about CSA prevention. Mothers and girls' parents were more willing to communicate with children about CSA prevention. The conclusion of the study was that parents appeared to have gained a positive attitude, but poor knowledge and practice. Their knowledge and skills of effective communication should be strengthened to promote CSA prevention practice.